VOTER REGISTRATION INFORMATION
1. If you are not registered to vote where you live now, would you like to apply to register to vote here today?
(X one)
YES NO
IF YOU DO NOT MARK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER
TO VOTE AT THIS TIME.
Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided
by this agency.
If you would like help filling out the voter registration application form, we will help you. The decision whether to
seek or accept help is yours. You may fill out the application form in private.
2. PRINTED NAME
4. DATE
(YYYYMMDD)
If you believe that someone has interfered with your right to register or to decline to register
to vote, your right to privacy in deciding whether to register or in applying to register to vote,
or your right to choose your own political party or other political preference, you may file a
complaint with:
Federal Voting Assistance Program
1155 Defense Pentagon
Washington, DC 20301-1155
Telephone Number: 800-438-VOTE
DD FORM 2645, NOV 2008
If you decline
to register to vote, that information will remain confidential and will only be used for voter registration
purposes.
If you register to vote, information regarding the office in which the application was submitted will remain
confidential and only be used for voter registration purposes.
3. SIGNATURE
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional 8.0
